Factors determining operative mortality of grade V blunt hepatic trauma

Background: Despite recent advances in the management of severe hepatic inj uries, the operative mortality rate of grade V hepatic injuries still range s from 67% to 80%. Grade V hepatic injuries involving the retrohepatic cava or main hepatic veins are almost always lethal, especially those from blun t trauma, The purpose of this study is to understand the risk factors deter mining operative mortality in grade V blunt hepatic trauma, and to try to i mprove the surgical management of these injuries, Methods: A retrospective study was conducted at a medical center that offer s services including primary, secondary, and tertiary care. Forty-four pati ents with grade V blunt hepatic injuries were treated during a 6-year perio d from January 1, 1991, to December 31, 1996, The operative mortality was c ompared by a multivariate analysis. Results: Forty-four patients with grade V blunt hepatic injuries were ident ified, Seven patients had only parenchymal injuries, and the others had vas cular and associated parenchymal injuries. Venorrhaphy was used in 37 patie nts; 29 were treated using a nonshunting approach, and 8 with an atriocaval shunt, The overall mortality rate was 68% (30 of 44), and liver-related mo rtality was 50% (22 of 44), Univariate analysis revealed that the significa nt variables affecting operative mortality were initial systolic blood pres sure, initial base deficit, the Glasgow Coma Scale, injury type, number of resected segments, and total intraoperative blood loss. Based on forward st ep-ping logistic regression analysis, patients with an initial base deficit of -6 mmol/L or less (relative risk = 17.3), and a total intraoperative bl ood loss of 5,000 mt or more (relative risk = 23.5) would, significantly, e ncounter a worsening prognosis. Conclusions: Initial base deficit and total intraoperative blood loss were the significant factors that determined operative mortality after grade V b lunt hepatic trauma. We suggest that prompt resuscitation and expeditious a nd appropriate surgical management, to control operative blood loss, is the only way to reduce operative mortality in patients with grade V blunt hepa tic trauma.